Minecraft & The Uncanny, Part 1

This is the first of a two part series on Minecraft.  Up until now you could only read it if you bought my book, but I am posting it here to give you a sense of what the book is like.  You can buy it here.  More importantly, I’m hoping you will find the topic interesting enough to vote for my presentation proposal on Minecraft & Mindfulness for SXSW this year.  You can do that here.

In 1919 Freud wrote and published an article on “The Uncanny.”  In it he described the concept of the uncanny as a specific type of fear something both strange and familiar.  It is worth noting that the article begins with an investigation into aesthetics, something that was not usually done in the medical literature of Freud’s time.  But Freud realized that there was something particularly aesthetic about the uncanny.  It is an anxiety that both draws on the aesthetic, and from a distance also acquires an aesthetic quality itself.  In fact, it could be argued that a whole genre of fiction, such as Lovecraft, embodies the aesthetic of the uncanny.

In German, the uncanny is unheimlich, which translates literally to the “unhomely” or “unhomelike.”  Here homely has a double meaning.  First homely is the quality of domesticity, the warm hearth of the house, down comforters, a cheery cottage coziness, etc.  Second, heimlich refers to concealment, contained within the house’s domestic sphere, hidden from the public eyes of outside society.

Seen in this light, the uncanny or unheimlich is both alien and a revelation or an exposure.  Freud quotes Schelling as saying that ‘“Unheimlich” is the name for everything that ought to have remained … secret and hidden but has come to light..’” Is it any wonder that Freud took up exploration of this concept, with all of its allusions to the unconscious, anxiety, and societal repression?

Freud also talks about the element of repetition in the uncanny, such as arriving at certain places we’ve been to before, or noticing the number 62 appearing throughout the day in a variety of places.  This element of repetition gives rise to the sense that there is a pattern that we may not be aware of, which in turn makes the world suddenly seem both stranger and more imbued with meaning.

Freud goes on to discuss something gamers will be very familiar with, mana, although he discusses it from outside the framework of fantasy as a form of magical thinking that attributes powers to the neurotic overvaluation of their thought processes and their impact on reality.  But the game world is within the realm of fantasy.  Within that world, what Freud refers to as “the Apparent death and the re-animation of the dead” are fairly commonplace.  The game world returns us in many ways to the animistic state of being, characterized by “the prompt fulfilment of wishes, with secret injurious powers and with the return of the dead.”

The uncanny also figures largely in the philosophy of Martin Heidegger, and is connected to the idea of man’s “throwness” into the world.  Human beings want to feel at home in the world, but when they encounter the uncanny they experience themselves as thrown into it and apart from it.  For Heidegger the unheimlich eradicates our sense of Being-at-home-in-the-World, but as it does so it reveals something about the World to us.

For Heidegger the World is also revealed to us (and we are revealed as well) by that which is ready-to-hand, something that has a meaning that connects us to the world.  An example is a hammer, which we experience as imbued with meaning and value and inextricably linked to human being.  We don’t think about the hammer, in fact the only time we are really conscious of it is when it isn’t working.  A similar example is your car, if you reflect on it you will probably notice that you only really pay attention to your car as a concept when it isn’t working.

As opposed to ready-to-hand, present-at-hand refers to an uninvested, detached way of looking at something, one that takes us out of any sort of meaningful relationship.  Its meaning may be unclear and unconnected with human being at all.  If I ask you what you’d like to do with that round green and red thing, you’ll be confused.  But if you see it as an apple, things will become much clearer.  It probably isn’t a coincidence, by the way, that most depictions of Adam and Eve in the Garden of Eden show the fruit as an apple.  Before the Fall, everything is ready-to-hand and imbued with meaning.  Afterwards, in our thrown state, things become less clear, and more uncanny.  Paradise has been lost.

Ninety years after Freud wrote “The Uncanny,” Markus “Notch” Persson created the game Minecraft.   Minecraft is a sandbox type of video game, meaning that the world generated can be permanently changed by the player.  Creativity and survival is the goal, and there is no way to “win” the game.  The premise of the game is that your character is thrown into a vast world designed with 8-bit graphics (think early Nintendo) with only your bare hands.  The game has a day and night cycle, and at night zombies, skeletons, and other monsters come out and will attack you if you are exposed.

Everything in the game world can be destroyed and broken down into elements that can be crafted if you have the right ingredients.  At first you have fewer options, because destroying a tree with your hands takes more time than if you had an axe.  But slowly you gather materials so that you can build things that in turn allow you to build more things, so that you can hopefully build a shelter before night falls.

The landscape of the world is randomly generated by the game, and remains saved if you are killed.  Dig a hole in the ground and it will be there when you return from the dead and to the game.  The graphics are not realistic, with the blocky edges of 8-bit design, which underscores the uncanny element of the world.  The world is vast, and looks like the real world, and also doesn’t.  Minecraft is not trying to trick you into thinking it looks like real life, in fact that is one of the things that makes it so immersive.

Part 2, next week.

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If Freud Had Played Video Games

This post is dedicated to my supervisee, Alex Kamin, who inspired me to make the connections. I learn so much from my supervisees!

Last night I spent a great deal of time mining for diamonds.  They are fairly rare, and can only be mined if you have an iron pickaxe (or a diamond one).  This meant that I needed to mine iron ore first with a stone pickaxe, but I should start at the beginning.

Minecraft is a game which now rivals WoW in popularity.  It has been around in beta for a while, but now has been released to the general public.  The game takes place in what is known as a sandbox world.  What that means is that the game world can be effected permanently by the player.  Dig a hole and it stays dug, chop a tree down and it stays chopped, plant new ones and in time they grow.  As opposed to having a beginning, middle and end, Minecraft can be played for as long as you like.  You can play it in single-player mode or log on to a minecraft server and participate in a multiplayer world.

Starting with nothing but her or his bare hands, your character takes materials from the environment and fashions tools, houses, works of art out of these raw materials.  That is the crafting part.  Once you have fashioned the most basic pickaxe, out of wood, you start to do the mining part.  Which brings me back to diamonds.

Diamonds are very rare blocks in Minecraft, and are mostly found at the bottom layer of the world.  You have to tunnel through loads of dirt blocks, stone blocks, and gravel blocks.  Sometimes you tunnel straight into lava and get burned up.  Sometimes the ground beneath you turns out to be a giant chasm and you plummet.  Sometimes there is water that floods your tunnel, or monsters if you are looking in one of the world’s many caves.

A lot of time is spent underground, but a big part of the game is to bring the materials back up to the surface.  There you make your crafting table, house, and forge.  Days and nights pass.  At night the monsters from the caves come out and roam the surface, and you’d better be in your house with the doors shut!

This is a very brief synopsis of an amazing virtual world that is already being used in classrooms and by families to provide cooperative and fun learning. You can find one such example, The Massively Minecraft Network, here.

One group who could benefit from understanding and playing Minecraft is psychodynamic psychotherapists, especially psychoanalytically-oriented ones.

For decades, psychology textbooks have used the iceberg to explain Freud’s early topographical model of the mind.  It’s the one I grew up as a therapist with, and you probably did too.  One version is this one:

Photo found on Allpsych.com

The topographical model introduces the concepts of the conscious, the preconscious, and the unconscious.  Freud was ultimately dissatisfied with this model, and moved on to his structural theoretical model of Id, Ego and Superego.  I wonder if he would have done so if he’d been able to play Minecraft.

Two of the deficits of the topographical model as pictured by an iceberg are its static nature and its failure to locate where and how psychotherapy works.  The second deficit derives from the first.  Psychodynamic therapy is as the name suggests, a moving process.  Now imagine playing the game I described above, and you have a dynamic model.  There is the conscious surface that changes over time, is constantly changing and growing, where things are visible.  There are the caverns and depths which are the unconscious.  And there is the preconscious twilight and night, when the monsters and creatures from the unconscious slip up to the surface and terrify us.

In terms of describing psychodynamic therapy, Minecraft makes that easy too.  I have often had a difficult time explaining to a patient what the unconscious is and why I think it is important.  But any gamer who has played Minecraft will understand the process of therapy and their work in it in the metaphors of mining.  During the week, our patients roam the surface of their psychosocial world.  Then one, two, or three times a week, they come into therapy and begin tunneling.  Week after week they mine dirt, stone, and occasionally strike a vein of insight.  Like iron ore, insight is a necessary but insufficient requirement for change.  Without smelting and crafting, iron ore can never become a tool we can use.  Likewise, without reflecting on our behaviors and changing them we can never improve our ego functions.

You can explain ego functioning via Minecraft as well, by discussing those above tools.  Tools in Minecraft include shovels, pickaxes, hatchets, swords, wool shears and hoes.  A hoe is excellent to use in gardening, whereas a sword will not function in the game that way.  You can chop down a tree with a pickaxe but it takes longer and wears down the pickaxe more quickly than if you were to use a hatchet.  Different ego functions do different things, and the ego defenses are only one subset of the ego functions.  Only one of the tools is explicitly made to be a weapon.

And if you lead with your ego defenses all the time you will be disappointed.  Take sheep for example.  If you kill a sheep with a sword you get one block of wool.  But if you shear it with the iron shears you get three wools, and the sheep lives to grow more wool.  By the way, if you craft a hoe you can grow wheat, which allows you to domesticate and breed sheep for even more wool.  Just so our ego functions, which provide a holistic and dynamic system that allows us to mediate the world and our wishes.

When you start mining you have a wooden pickaxe.  You mine stone so you can get a stone pickaxe.  You mine iron ore with the stone one.  Only iron pickaxes can mine diamonds.

Psychotherapy takes time and effort, lots of time and effort, if you are aiming for more than symptom reduction.  Patients begin with the raw tools they started out with, and build on each developmental gain.  Often our patients will feel very raw and discouraged, state that they despair of ever getting better, whatever better means to them.  When that happens we can remind them that therapy is minecraft.  It takes delving and work back on the surface in the real world outside the office.  It takes time and patience.  Sometimes they will feel consumed by feelings as hot as lava, or flooded by memories like water in a mineshaft.  Sometimes it will feel like they’ve lost everything they’ve been carrying and have to start over.  But with each set of tools they acquire they’ll find it easier to make their way in the world.

And sometimes they will find diamonds.


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Save and Continue

Recently I was playing God of War III, and noticing something I take for granted much of the time, the savepoint. This is something that has become so integrated into video games that gamers hardly notice it after we discover what the particular “savepoint” looks like in the game we are playing. The saved game has been around for decades, and has become increasingly important as games have grown in length and complexity. I was reminded recently by Nancy Rappaport, a colleague and attending psychiatrist at Cambridge Health Alliance about how the concept of the saved game may not be taken for granted. I was trying to explain to Nancy during a workshop certain gaming concepts, and she was explaining that her point of reference in playing video games was Pac-Man, and in a general sense video games from an arcade setting that early on didn’t always have savepoints, where the player was asked if they wanted to “Save and Continue.”

This may be useful to remember when you are becoming frustrated with a gamer who is not as concerned with the quantitative time (bedtime, for example) as they are with the qualitative time of getting to the savepoint. But that actually isn’t what this post is going to be about. Instead I want to return to the concept of what makes an Epic Therapist here:

Epic Therapists remember the importance of saving and continuing.
To start with, therapy is in many ways a savepoint. At certain times in their lives or week our patients arrive at our office, pause, and take stock of things. In his 1914 paper “Remembering, Repeating and Working-Through” Freud alludes to this when he remarks that “In these processes it particularly often happens that something is ‘remembered’ which could never have been forgotten because it was never at any time noticed–was never conscious.” Like the savepoint in a game, the patient arrives at the place for the first time, understands how important it is to hold on to that progress, and remembers or saves it from repression. But part of what makes therapy therapy is the therapeutic frame, and at some point the session ends, and the patient goes back out into the rest of their life. They can’t just stay at the savepoint, they have to continue.

Readers have probably noticed by now that I draw frequent parallels to psychoanalytic theory and video games, and this is no exception. Our profession has a rich theoretical history that has grown from individual therapists learning from each other, disagreeing with each other, building on the prior work of each other and diverging from each other. Psychology as a field to flourish has had to frequently “save and continue” by writing these theories down in journals and now blogs, to take stock of what we have learned, but we’ve also had to move forward and continue to challenge pre-existing models. It can never be just save or just continue: To just save would stagnate our thinking and practice, and to just continue would mean we never consider thoughtfully the work we are doing.

In many ways, the problem with healthcare has been few if any savepoints, discouraging providers from taking time between patients to reflect before continuing on to the next patient. Interns in mental health agencies have many no-shows, and with no infrastructure to hold patients responsible to keep their appointments, these interns “continue” through the years where they should be receiving the most training with a fluctuating and diminishing number of patients to practice their craft under supervision.

Ask yourself this: If you were about to have open heart surgery and the doctor told you that he had only had the opportunity in medical school to practice the procedure 3 times because most of his patients cancelled or no-showed, would you feel confident in their ability? And yet we crank our interns through graduate programs based on the number of years rather than skills acquired, because the healthcare system is flawed and and patients are not held accountable for missing/cancelling appointments. This isn’t the interns’ fault, they are trying to get through to their knowledge and experience “savepoint,” but graduate schools and placements inadvertently become the parent shutting off the light because its “bedtime,” and we are producing generation after generation of clinicians who have had inconsistent or insufficient practice. This is continue without the save.

On the other hand, let’s take a look at the radical save mentality that permeates our profession. There are certain parts of the way many of my colleagues practice psychotherapy which have become extremely fixed, and I too fall prey to this at times. The 45-50 hour, a certain therapeutic stance, and my favorite, shunning technology. They bar their adolescent patient’s cellphones at the door rather than exploring who is texting them, refuse to consider Skype as an option let alone suggest it to their patients.

I frequently get referrals emails from several listservs, looking for therapists in Seattle, London, or Singapore. I enjoy practicing in-person therapy immensely, but does it ever occur to these colleagues to consider beginning to practice online as well? Why refer a patient to someone in Taiwan based on location when you could have one of your colleagues whom you know and respect take the patient on? On occasion I reply to these referral requests asking if the patient would be interested in Skype, but for the most part I’ve become reluctant to do that because I am pretty sure it doesn’t go anywhere. In terms of technology these psychotherapists are often in a lock-down save mode, and I foresee that they will resist change as the world continues without them.

My friend and colleague Susan Giurleo and I often find these things frustrating, and I realized today one reason why we may have this in common. We both went to Connecticut College in the late 80s early 90s, between the college presidency of Oakes Ames and Claire Gaudiani. In fact our graduating class became known as “the folks who knew Oakes.” And during this time our college had a motto that was drilled into all of us: Tradition and Innovation. Everywhere we looked, in all the college information and stationary were those words, tradition and innovation. Save and continue.

I have definitely tried to live that in my profession and my life of the mind. I’m a psychodynamically oriented therapist who uses Twitter and plays video games. I teach my students about Freud and Facebook. And I think that perhaps the affinity I find in the fin de siecle of the 19th century is how its denizens struggled to save and continue, to embrace the advances of technology then as we do now in the 21st century. In a recent article at boston.com Chris Brogan alluded to this when he said, ““The excitement for me about [social media] is, it’s gone from ‘Gee whiz!’ to ‘Now what?’ ”

Technology is here to stay and embedded in our lives, and today, like after the Industrial Revolution, we must learn the “now what?” To do this we can’t just rush forward and forget everything we ever knew, but we can’t stay stuck in a mindset from the pre-IBM world. Web 2.0 has arrived, and we need both tradition and innovation if we want to progress.

We must save and continue.

The Gamification of Psychotherapy

“Ring Around The Rosy by W. Earle Robinson

In the 19th century Sigmund Freud revolutionized the fields of neurology and psychiatry.  Whether you agree or disagree with the particulars, psychoanalytic theory, and the psychodynamic theories that sprang from it changed the way we understand the human mind.  Freud pioneered our understanding of the psychosomatic illness, conflicts, drives and the unconscious, to name but a few of the ideas that still influence theory and practice of psychotherapy today.

The way Freud came to understand and then attempt to help us understand these ideas was by applying other theoretical models to our psychology.  The industrial revolution, with its steam-powered hydraulics and locomotives powered by internal pressure, heavily influenced his beginning work of trauma affect and drive theories.  His famous topographic model of the psyche, with its strata of conscious, preconscious and Unconscious, was inspired by the advances in geology and archaeology of his day.  In short, the technological advances of his time informed and shaped the way he thought about and worked with people.

Now we are in the 21st century, which is new enough that saying it still fills us with amazement.  The revolutions in technology continue, and I want to begin applying some of these technological advances to my theory and practice.  I have blogged a lot about games, and today I want to discuss the application of game theory in understanding the human psychology.

Gamification is the act of using the elements of game design and applying it to other parts of human existence.  We have seen gamification begin to be used in businesses like IBM and written about in the Harvard Business Review.  MacDonald’s has been using gamification with its’ Monopoly game for years.  The Army has been using viedo game technology to gamify our defenses.  Socially Serious Games like Against All Odds are being used to educate people about human rights and global conflict.  So can gamification be applied to psychotherapy?

I think so.

In her new (and excellent!) book Reality Is Broken, Jane MacGonigal reminds us of the concise yet brilliant description of what a game is according to Bernard Suits.  Suits states that “playing a game is the voluntary attempt to overcome unnecessary obstacles” in his book The Grasshopper.  An example of would be chess where we agree to use the playing pieces on the board, the unnecessary obstacle is that each type of piece can only move a certain prescribed way, and we attempt to overcome this in order to capture the king of our opponent.

One example of gamifying psychotherapy is if we posit something similar:  Psychotherapy is the voluntary attempt to overcome unnecessary obstacles.

Psychotherapy must be voluntary to be successful. If the patient refuses to engage in the process either by physically or mentally absenting himself, therapy will not happen.  Yet even people mandated to treatment can benefit from it if they agree subconsciously to engage with us.  Adolescents who are dragged to treatment will sit with us in stony silence week after week because they are not there voluntarily.  Sometimes we can get a part of them to come out and “play,” i.e. engage with us.  And if we don’t want to work with the patient for some reason, it makes treatment next to impossible.

Patients come to us because they are attempting to overcome something.  They don’t just drop in because they wanted to read the magazines in the waiting room.  Something in their life has caused them pain, sadness, anger, discomfort and they want that to stop.  They may have noticed a pattern of bad relationships, they may be having traumatic flashbacks, they may be encopretic.  But something in their life outside the therapy office has seemed insurmountable, and they want our help in overcoming it.

Which brings us to the unneccessary obstacle.  I would suggest that in many cases the symptom is the unnecessary obstacle.  Whatever the behavior might have been in the past it is no longer necessary now.  As a child, hiding their body or mind may have been necessary to keep themselves safe from an abusive parent or sibling.  As an adult, their tendency to dissociate in meetings and avoid success at work is an unnecessary obstacle.  As a teen a patient may try to control an out of control environment in order to feel a sense of self.  As an adult they may seek to control their bodies through disordered eating or self-injury for much the same reason.  The challenge here is that the patient continues to go through life unconscious of this and acting as if the obstacle was necessary.  In a sense they are playing out (albeit very seriously and sometimes fatally) something outside of the playground.

Huizinga referred to the “magic circle” of play, within which the game unfolds.  Therapy, with its 45-50 minute hour, office setting and professional boundaries, is such a magic circle.  If you don’t take the idea of play seriously, you will probably find this analogy offensive.  But in my opinion play is very serious.  In psychotherapy, patient and therapist become earnestly engaged in the immediacy of what happens.  People become ghosts of other people, monsters appear, and ancient kingdoms rise up from beneath the waves for a day.  I believe that most people who have been in treatment will be able to recall the immersive and powerful experiences they have had there, experiences which have felt tragic and heroic.  Hopefully the patient leaves the magic circle having changed, the unnecessary obstacle is overcome, and life gets better.

We live, as Freud did, at the threshold between two centuries.  We live, as Freud did, in a world story frequently punctuated by war.  I imagine that back then things felt as difficult, healing seemed as urgent as it does today.  People came to Freud then, and us now, to help them overcome unnecessary obstacles that were ruining their lives.  Freud benefited from applying the diverse technologies of hydraulics, geology and archaeology to understand the human condition; and I believe that we can benefit from applying ludology and game theory to the serious business of therapy.  Gamification will not be used to “lighten up” treatment but rather deepen it.  Patients who play video games may respond better to leveling up than treatment planning, power-ups as opposed to coping strategies.  Virtual worlds may serve as practice for real ones, just as therapy has served as practice for other relationships.

Freud was an Epic Therapist.  He researched and synthesized what was going on in the art and science of his day in order to do better treatment.  Today’s Epic Therapists will need to do the same, and that means having the courage to play with technology, games and ideas.  Our resistance to doing so is an unnecessary obstacle we need to overcome, and our success in achieving this will be an Epic Win for our patients and our profession.

New Lease on Second Life

So let me introduce you to Sigmund Steampunk, my avatar on Second Life.  I have already learned that there is more to Second Life and avatars than learning how to “walk” in the virtual world.  One of the lessons came from my supervisor, whom I value and idealize immensely, and who has only begun to learn about avatars and SL through our work together.  So the other day I emailed her and included the above photo of Sigmund, mentioning that since we’d been discussing it I thought she’d find it interesting to see what I was talking about.  She did, and then she lightheartedly mentioned that Sigmund looked like a slightly anorexic version of Ellen DeGeneres…

Lesson #1   Avatar Cathexis

People who experience avatars from the “outside in” don’t always understand immediately how cathected the user can be to them.  When I say cathexis, I am referring to the psychoanalytic concept of emotional and or libidinal investment in the object.  In most MMORPGs and virtual worlds the user has some to a lot of input into how to design their avatar.  The result?  The more time one spends shaping one’s avatar, the more emotionally invested in it one can become.  I was reminded of this when I read the less than flattering description of Sigmund:  I was taken aback by the fact that the description actually had an emotional impact.  Namely, ouch!

And when I noticed the ouch, I noticed that there was a stronger cathexis than I had bargained for.  So when you are given the opportunity to meet one of your patient’s avatars, tread carefully.  You don’t know how emotionally invested they are in their avatar.  They may not know how emotionally invested they are in it.  I know that we will have a rewarding supervision session next time, and I know that my supervisor will “get it.”  But I will think twice before introducing her to my level 80 draeni mage from World of Warcraft.  Sigmund has only been around for a few months, the mage has been around for 4 years!  Another example of avatar cathexis is said mage.  I recently wrote a two-part article for my local NASW paper on online gaming.  My co-author asked me what licensure or work qualifications I wanted included in my byline.  I wanted to include that I was an assistant faculty at Harvard Medical School and a level 80 draeni mage.  She informed me that NASW wouldn’t consider the mage qualification professional enough.  Again, ouch!  Do you know how many hours it took to level that guy?  We’ve been through thick and thin, and I consider him as source of pride on par as my Harvard appointment.  Looking at that from the “outside in” you may think that is bizarre.  But in terms of avatar cathexis it makes perfect sense.

Lesson #2  Avatar’s are fraught with meaning, conscious and unconscious meaning.

Now that I look at Sigmund, I can clearly see what my supervisor was describing.  I could make excuses, in truth I wanted his hair to be more dirty blonde like mine but couldn’t figure out how to do that.  But the reality is, I hadn’t been entirely conscious of my wish to be a few pounds thinner.  But there is my wish fulfillment, standing there waving at us.  Luckily I can tolerate seeing it.  Some of our patients may have a harder time.  Some may want to have more powerful bodies, others may want bodies assigned a different gender, still others want to give their avatar a chance at childlike innocence they never had, as the latest issue of TILT describes in “Alice in VirtualLand.”

So when exploring your patient’s avatar, tread carefully.  But definitely explore it, the avatar is a gift to the treatment.  It is wish fulfillment, idealized self, object relation, projection and IFS part all rolled up in one!  If you are a psychodynamically oriented psychotherapist, you’ll be amazed at what comes up for your patient when you start to express interest in getting to know their avatars.  And if you express disinterest, you have made a great empathic failure, and like all such empathic failures, you need to correct it ASAP.

In Second Life, there is a lot of joking about the bumping into things that first happens “inworld” when a user starts to try to move her or his avatar around.  I see this as also a metaphor for integrating avatar therapy into your treatment repertoire.  I have no intention of beginning to start having sessions with patients virtually in SL any time soon.  But I can see that a day may be coming when that will be part of meeting them where they are at.  I don’t want to be bumping around into walls or ego defenses, so I am practicing a little now, on my own time.  Many of the people I supervise around technology want to jump right in, and I applaud their enthusiasm.  I also caution them that we didn’t start meeting with patients before we had had at least some education in how to practice therapy, and that the same applies for learning to navigate Web 2.0.

What technology are you willing to play with and learn about before you are asked to by a patient?  Where will you go this week?

Secret Formula PB+5

I have frequent consults with beginning or seasoned practitioners looking to get on Medicaid as private practitioners.  Their logic on the surface makes a lot of sense coming from their agency backgrounds.  A majority of their patients in agency are on Medicaid, and they may want to keep them as they transition to private practice.  And many of us went into this work because we want to help a range of people, including the most impoverished or differently abled.  These are laudable goals, and I want to assert that they are not incompatible with private practice.  But I do think that Medicaid is, at least in terms of building one.

What happens when your patient misses their appointment?  With Medicaid you cannot charge them for a missed appointment.  And after they miss two or three, you may have the conversation about “are you really interested in treatment?”  They say yes, miss again, and you fire them, or don’t call them back and feel guilty and frustrated; or they drop out of treatment feeling like they’ve failed yet again.  And in Massachusetts, the newest vendor of Medicaid, Beacon Health Strategies, is trying to change the provider contract to say that you are not allowed to fire them for no-shows!  Outrageous, but hey, you signed the contract, so until NASW or APA fights this statewide that is your agreement.

This is such a lose-lose!  Private practitioners are not able to make a living, low-income patients are not able to get consistent treatment, and everyone feels like a failure, except the insurance company which pays nothing.  But there is a way to build social justice and healthy treatment into your practice right at the beginning, I call it my Pro Bono + 5 session.

Imagine this, you decide that you want to start out in private practice, and while you are building it you want to be able to take referrals from your old agency, which usually has mostly Medicaid patients.  So you call them and let them know that you have 2 immediate openings for your pro bono plus 5$ sessions.

Your what?

You explain that while you don’t take Medicaid, you are offering two sessions in your practice where you contract with the patient that as long as they are on Medicaid you will never charge them more or less than $5.  You don’t participate in Medicaid, but you won’t bill Medicaid either.  You’ll only ask them for a nominal $5 fee payable each week as part of your committment to building a socially just practice.  When you meet the patient, you explain this to them, and explain your no-show policy.  They keep their appointment, they pay the $5.  They miss the appointment, they pay the $5.  If they’re sick or unable to make the session, you’ll gladly offer them a phone session, because they’ll still be paying the $5.  This is made clear the first appointment, with whatever your normal policy is.  You see, you can’t do phone therapy on Medicaid, but on your PB+5 plan you can.  For the patient, they are getting a great discount and affordable treatment.   For the beginning private practitioner you are getting great clinical experience, including talking about the fee and your therapeutic contract, and feeling like you are doing some diverse work, which hopefully helps you feel more confident in being circumspect when filling the rest of your week.  The referring agency gets to win in that they can refer someone immediately.   Win-win.

This is not a new concept.  Freud created the Vienna Ambulatorium to provide free psychoanalysis almost 90 years ago.  We all know that Freud saw many upperclass patients, but he also allotted some time for low-cost or free treatment.  You can do the same.  And I suggest that you set a fixed number of sessions right at the start of your practice, which will help you later keep the number of full-pay or insurance appointments fixed as well.  So what do you think?